| 1. |
- Apelqvist, Jan, et al.
(författare)
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Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome
- 1992
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Ingår i: Journal of Diabetes and its Complications. - 1873-460X. ; 6:3, s. 167-174
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Tidskriftsartikel (refereegranskat)abstract
- The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.
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| 2. |
- Apelqvist, Jan, et al.
(författare)
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The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers
- 1990
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Ingår i: Journal of Diabetic Complications. - 0891-6632. ; 4:1, s. 21-25
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Tidskriftsartikel (refereegranskat)abstract
- The influence of external precipitating factors and the presence of peripheral neuropathy on the development and outcome of foot ulcers were evaluated in 314 consecutive diabetic patients. All patients were treated by the same foot care team. Each patient was represented by one ulcer, and primary healing was defined as intact skin for at least six months. External precipitating factors were identifiable in 264 of 314 patients. The most common factors were ill fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia. The highest primary healing rates were seen in lesions caused by paronychia (84%) and stress ulcer (76%). Clinical signs of sensory and muscular disturbances were seen in the majority of patients (96%). Sensory neuropathy, evaluated with a biothesiometer, was more common among patients who had had amputations or, died subsequently compared to those who healed. This study suggests that a majority of diabetic foot ulcers might have been prevented, since a precipitating external factor was identified in four of five patients, stressing the importance of preventive foot care.
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| 3. |
- Larsson, Jan, et al.
(författare)
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Local signs and symptoms in relation to final amputation level in diabetic patients. A prospective study of 187 patients with foot ulcers
- 1994
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Ingår i: Acta Orthopaedica Scandinavica. - : Medical Journals Sweden AB. - 0001-6470 .- 1745-3674. ; 65:4, s. 387-393
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Tidskriftsartikel (refereegranskat)abstract
- Local signs and symptoms were evaluated in 187 consecutively presenting diabetic patients undergoing amputation for foot ulcers. From admission until final outcome the patients were treated by the same multidisciplinary team both as in- and out-patients. At the time of amputation, the types of lesions were superficial/deep ulcer (n 17), ulcer with deep infection, but without gangrene (n 40), and gangrene with or without infection (n 130). Healing after a minor amputation (below the ankle) occurred in 74 patients, while 88 patients healed after a major amputation (above the ankle), and 25 patients died before healing had occurred. Deep infection and presence of popliteal or pedal pulses were associated with healing after minor amputation and so were ulcers on the small toes, metatarsal head area and midfoot. Pain, progressive gangrene, intermittent claudication, and decubital and multiple ulcers were related to healing after major amputation. In a logistic regression analysis, pain, progressive gangrene and intermittent claudication remained. However, none of these factors excluded healing of a minor amputation and thus selection of amputation level in diabetic patients with foot ulcers cannot be based upon these factors exclusively.
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| 4. |
- Larsson, Jan, et al.
(författare)
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Long-term prognosis after healed amputation in patients with diabetes
- 1998
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Ingår i: Clinical Orthopaedics and Related Research. - 0009-921X. ; :350, s. 149-158
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Tidskriftsartikel (refereegranskat)abstract
- In this prospective study, mortality, rehabilitation, and new amputations on the same or on the contralateral leg were studied in 189 patients with diabetes who had achieved healing of an index amputation. Ninety-three patients had achieved healing after an index minor (below the ankle) and 96 after an index major (above the ankle) amputation, precipitated by a foot ulcer. The healing time was 29 weeks (range, 3-191 weeks) with a minor amputation and 8 weeks (range, 3-104 weeks) with a primary major amputation. The mortality 1, 3, and 5 years after the index amputation was 15%, 38%, and 68%, respectively, and was higher in patients who had achieved healing after major amputation than in patients achieving healing after minor amputation. The rate of new amputations after 1, 3, and 5 years of observation was 14%, 30%, and 49%, respectively. There was no difference among patients with an index minor and those with an index major amputation. The rate of new major amputations was 9%, 13%, and 23%, respectively, and was higher in patients with an index major amputation. Eighty-five percent of new amputations were precipitated by a foot ulcer. Patients living independently before the index amputation returned to living independently more often after a minor than a major amputation (93% versus 61%). One year after the index amputation, 70% of patients who had achieved healing after having a minor amputation and who could walk 1 km or more before amputation had regained this walking capacity, compared with 19% of patients having a major amputation. Seventy percent of patients with an index transtibial amputation who could walk before amputation were fitted with a prosthesis, and 52% were using it regularly. Patients with diabetes who had an index major amputation had a higher mortality, an equal rate of new amputation, and a lower rehabilitation potential than did patients who had an index minor amputation.
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| 5. |
- Apelqvist, Jan, et al.
(författare)
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Long-term prognosis for diabetic patients with foot ulcers
- 1993
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Ingår i: Journal of Internal Medicine. - 1365-2796. ; 233:6, s. 485-491
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. DESIGN. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. SETTING. A multidisciplinary foot-care team. POPULATION. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. MAIN OUTCOME MEASURES. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. RESULTS. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. CONCLUSION. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation.
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| 6. |
- Apelqvist, Jan, et al.
(författare)
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Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer
- 1989
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Ingår i: Diabetes Care. - : American Diabetes Association. - 1935-5548 .- 0149-5992. ; 12:6, s. 373-378
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Tidskriftsartikel (refereegranskat)abstract
- The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.
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| 7. |
- Apelqvist, Jan, et al.
(författare)
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The association between clinical risk factors and outcome of diabetic foot ulcers
- 1992
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Ingår i: Diabetes Research and Clinical Practice. - 1872-8227. ; 18:1, s. 43-53
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. The aim of the study was to describe the association between clinical risk factors in diabetic patients with food ulcers in relation to outcome. DESIGN. A prospective study of 314 consecutively presenting diabetic patients with foot ulcers referred to the Department of Internal Medicine between July 1, 1983 and June 30, 1987. All patients were followed to final outcome. SETTING. All patients were treated by the same multi-disciplinary foot care team at the Department of Medicine, both as in- and out-patients. Healing was defined as intact skin for at least 6 months. RESULTS. One hundred and ninety-seven patients healed primarily, 77 after amputation, and 40 died unhealed. Signs of macroangiopathy were more common among patients who healed after amputation. The outcome was strongly related to age, though 43% of the patients with an age over 80 years healed primarily. There was no difference in smoking habits between patients who healed primarily and those who required amputation to heal. Diabetic nephropathy was found in 26% of the patients and was strongly associated with amputation. Presence of retinopathy was found in 54% of the patients, but this finding was not related to the outcome. There were no differences in short-term metabolic control as assessed by hemoglobin A1c levels between patients who healed primarily and those who healed after amputation. CONCLUSION. The presence of diabetic foot ulcers was strongly associated with age and diabetic complications such as multiple cardiovascular disease and nephropathy, which were important factors related to amputation.
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| 8. |
- Apelqvist, Jan, et al.
(författare)
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The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers
- 1990
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Ingår i: Diabetic Medicine. - 1464-5491. ; 7:7, s. 590-594
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Tidskriftsartikel (refereegranskat)abstract
- In a prospective study, peripheral pulses, claudication, peripheral oedema, and rest pain were evaluated in 314 sequentially presenting diabetic patients with foot ulcers. In the ulcerated limb pedal pulses were found to be present in 44% of the patients, peripheral oedema in 38%, and rest pain in 19%. Twelve per cent had claudication. Presence of pedal pulses was more common in patients whose ulcers underwent primary healing (56%) than in those who healed after amputation (23%) or died (25%, p less than 0.001). Eighty per cent of the patients with pedal pulses present underwent primary healing. However, 49% of patients with absence of pedal pulses also underwent primary healing and 12 patients developed gangrene despite presence of pedal pulses. Peripheral oedema was more common in patients who required amputation (58%) or died (55%) than in patients with primary healing (26%, p less than 0.001). A tentative predisposing factor was identified in 95% of the patients, the most common factors being neuropathy, congestive heart failure, and previous deep venous thrombosis. Rest pain was more common in patients who required amputation (48%) or died (23%) than in those with primary healing (7%; p less than 0.001). Only 50% of patients with gangrene had rest pain and of these patients, only one underwent primary healing. The presence of pedal pulses, oedema, and rest pain give valuable but imperfect information on the possible primary healing of foot ulcers in diabetic patients.
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| 9. |
- Apelqvist, Jan, et al.
(författare)
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Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers
- 1989
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Ingår i: Diabetic Medicine. - 1464-5491. ; 6:6, s. 526-530
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Tidskriftsartikel (refereegranskat)abstract
- The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.
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| 10. |
- Larsson, J, et al.
(författare)
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Clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers: a prospective study of healing below or above the ankle in 187 patients
- 1995
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Ingår i: Foot & Ankle International. - 1944-7876. ; 16:2, s. 69-74
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and out-patients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patients died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration. In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.
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